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In their informative article, McKechnie et al underestimate the risks facing undergraduate general practice from the forthcoming Medical Licensing Assessment (MLA).1 Through its focus on diagnoses, investigations, and technological solutions, the MLA overlooks the ‘whole patient’ perspective of general practice.2,3 The MLA adopts a Single Best Answer (SBA) structure and its content seeks to reflect expectations for Foundation Year 1, that is, rotations that take place in hospital and not general practice. These circumstances leave the general practice perspective as ‘postgraduate’ learning. In so doing, the MLA omits the daily challenges of the GP where there usually exists no single best answer.
More broadly the MLA risks coaxing students into the ‘therapeutic illusion’. Historically, this term described the false belief that doctors were ‘curing’ self-resolving minor illnesses. Today, its reach is far greater: persuading students of the inherent value of pursuing tests, prescriptions, and technological solutions. By contrast, one half of the consultations in general practice have no meaningful diagnosis, and other strategies, therefore, must by employed.3 Teaching students to navigate the primary care ‘corridor of uncertainty’ through generalist principles is key to preparation for all generalist settings but is absent from the MLA.3 This is a missed opportunity because it is in consultations without recourse to technological solutions that students can best hone their skills in communicating, sharing management plans, and safety-netting.
The MLA has wider implications for undergraduate curriculum content that could devalue general practice. For example, one response has been curriculum re-design to focus Year 5 entirely upon preparation for the MLA and for Foundation Year 1. In this model, general practice is required to create space by bringing placements forward to earlier years in the curriculum. If this strategy proves successful in any future school league table of MLA performance, other institutions will likely follow suit. Given that Year 5 placements constitute a ‘critical window’ for career choice, this has implications for GP recruitment. The MLA may also affect contextual learning by exerting an ‘upstream’ influence on assessment in earlier years of the curriculum. Important learning that risks being overlooked include the role of general practice in promoting environmental sustainability and in tackling health inequalities by widening access.
The MLA model only recognises the portion of general practice that aligns with clinical decision making in the hospital. Failure to prepare students more broadly for primary care is wholly incompatible with the government’s call for 50% of students to train in general practice.
The MLA, therefore, adds to longstanding, broader challenges facing those promoting general practice in the undergraduate curriculum and as a career choice.2
In order to refocus the MLA on the GP perspective, we call for the General Medical Council to reconsider its SBA model and for Foundation doctors to commence general practice rotations in Year 1 (rather than in just Year 2). This direct link between undergraduate and postgraduate general practice is fundamental to redefining MLA content, addressing the GP workforce crisis, and supporting learning across the primary and secondary care divide. By overlooking the GP perspective, the MLA may worsen the ‘serious tensions’ that exist between undergraduate teachers who are GPs and those who are hospital specialists.4 In so doing, it would undermine efforts over recent years to create a level playing field in the undergraduate curriculum.
- © British Journal of General Practice 2022